Medi­care — Are you an in-pa­tient or an out-pa­tient?

If you stay overnight in the hospi­tal, your costs and cov­er­age will depend on whether you have in­pa­tient sta­tus or out­pa­tient sta­tus in the hospi­tal. Stay­ing overnight in the hospi­tal does not make you a hospi­tal in­pa­tient. You only be­come an in­pa­tient af­ter your doc­tor for­mally ad­mits you to the hospi­tal.

In gen­eral, doc­tors will only ad­mit you if they ex­pect you will need to stay at least two days overnight in the hospi­tal. Part A cov­ers most of your care when you have in­pa­tient.

How­ever, when you are in the emer­gency room or in the hospi­tal un­der ob­ser­va­tion, you are usu­ally an out­pa­tient. You may be un­der ob­ser­va­tion if your doc­tor is keep­ing an eye on you to de­cide whether or not to ad­mit you. Ob­ser­va­tion ser­vices may look and feel ex­actly like in­pa­tient ser­vices. Ob­ser­va­tion can last just a few hours or longer. Part B cov­ers your care, in­clud­ing ob­ser­va­tion ser­vices, when you have out­pa­tient.

Whether your care gets cov­ered un­der Part A or Part B makes a dif­fer­ence. You will likely pay more for care if it’s con­sid­ered out­pa­tient rather than in­pa­tient. It also ef­fects whether you may qual­ify for Medi­care to pay for your stay in a skilled nurs­ing fa­cil­ity (SNF) af­ter you leave the hospi­tal. See be­low for more in­for­ma­tion.

Your pa­tient sta­tus can change dur­ing your stay. Ask if you are an in­pa­tient or out­pa­tient re­peat­edly. If you are un­able to ask this your­self, your fam­ily mem­bers and care­givers can ask for you.

Read be­low to learn about your costs for hospi­tal care as an in­pa­tient or out­pa­tient. The costs dis­cussed be­low ap­ply to those with Orig­i­nal Medi­care. If you have a Medi­care Ad­van­tage Plan, your costs in the hospi­tal may be dif­fer­ent. Con­tact your plan for in­for­ma­tion about what you pay for an in­pa­tient or out­pa­tient hospi­tal stay.

Costs for in­pa­tient hospi­tal care

When you are ad­mit­ted to a hospi­tal as an in­pa­tient, you pay a one-time de­ductible for most hospi­tal care pro­vided and then have no co-pay­ments for the first 60 days. (In 2016 the hospi­tal de­ductible is $1288.) Medi­care Part A cov­ers nurse’s ser­vices, med­i­cally nec­es­sary med­i­ca­tions, X-rays, sup­plies, ap­pli­ances, and equip­ment the hospi­tal pro­vides for you to use dur­ing your in­pa­tient hospi­tal stay. Medi­care Part B cov­ers doc­tors’ ser­vices you re­ceive in the hospi­tal. You usu­ally owe a sep­a­rate 20 per­cent coin­sur­ance for these doc­tors’ ser­vices.

Your sta­tus as a hospi­tal in­pa­tient may qual­ify you for Medi­care to pay for a Skilled Nurs­ing Fa­cil­ity (SNF) stay if you need it af­ter you leave the hospi­tal. In or­der to qual­ify for a Medi­care-cov­ered SNF stay, you must have been a hospi­tal in­pa­tient for at least three days and meet other re­quire­ments. The day you be­come an in­pa­tient counts to­ward the qual­i­fy­ing days; the day the hospi­tal dis­charges you does not count to­ward the qual­i­fy­ing days.

Costs and cov­er­age for out­pa­tient hospi­tal care

If you are an out­pa­tient dur­ing your hospi­tal stay, Medi­care Part B cov­ers most of your ser­vices. You typ­i­cally pay a coin­sur­ance for each med­i­cal ser­vice you re­ceive in the hospi­tal af­ter you meet the Part B de­ductible. For ex­am­ple, you will have sep­a­rate charges for emer­gency room care, ob­ser­va­tion care, x-rays and lab tests. You must also pay the coin­sur­ance for physi­cian ser­vices you re­ceive. Physi­cian ser­vices in­clude any time you spent with a physi­cian while you were in the hospi­tal, even if that physi­cian was not your pri­mary doc­tor or sur­geon. Orig­i­nal Medi­care Part B gen­er­ally cov­ers 80 per­cent of the cost of most ser­vices you re­ceive af­ter you have met your yearly de­ductible. In most cases, you are re­spon­si­ble for pay­ing the re­main­ing 20 per­cent coin­sur­ance.

When Part B cov­ers your hospi­tal care, you may have higher costs than if Part A cov­ers your stay.

You may have mul­ti­ple coin­sur­ances. Each in­di­vid­ual co­pay­ment must be less than the Part A de­ductible ($1,288 in 2016). How­ever, if you add up the coin­sur­ances for each ser vice the to­tal could be higher than the Part A de­ductible. Part B will not cover the cost of your pre­scrip­tion med­i­ca­tions that you rou­tinely take. You will need to get them cov­ered by Part D. If the hospi­tal phar­macy is not in your Part D plan’s net­work, you typ­i­cally have higher out of pocket costs than you would at an in­net­work phar­macy.

You will need to pay the hospi­tal for these med­i­ca­tions and then send the bill to your Part D to pay its share of the costs. The days spent as an out­pa­tient do not qual­ify you for a SNF stay. As a re­sult, you will need to pay the full cost your SNF stay. Medi­care Part B may pay for cer­tain skilled ser­vices (like phys­i­cal ther­apy) you re­ceive while stay­ing in the SNF.

Mike Zim­mer is pres­i­dent of Bay State In­sur­ance Agency Ltd. in Centreville. He may be reached at 410-758-1680.